Countdown to 2004 JCAHO SurveyBWH Nurse - For and about the Nursing Staff of Brigham and Women's Hospital
Countdown to 2004 JCAHO SurveyBWH Nurse - For and about the Nursing Staff of Brigham and Women's Hospital
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July 18, 2003
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In This Issue:
Continuing to Build the Nursing Diversity Fellowship Program
Dear Nurse Colleague:
Editorial Advisory Board
BWH Nursing Announces New Tagline
Cardiac Surgery RNs Attend Annual Conference
Entering the Mind Zone
BWH Welcomes New Sexual Assault Liaison
PACU Nurse Elected President of Massachusetts Chapter of ASPAN
MDs/RNs Celebrate 3rd Annual Medical Housestaff Nursing Awards
Countdown to 2004 JCAHO Survey
ON MY SHIFT
Welcome
Calendar
MICU Move in Progress
What You Need to Know
BWH’s next site survey from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is slated for January 2004. To help prepare nurses for the impending survey, BWH Nurse will continue to publish regular articles on appropriate processes and standards that apply to Nursing. All nurses, who have not yet been through a JCAHO Survey, should work with their nurse managers and clinical educators to ensure understanding and expectations of the process.
Part VI: Frequently Asked Questions on HIPAA Privacy Regulations
The HIPAA privacy regulations have been in effect since April of this year and there are a number of questions being raised by nurses in relation to compliance with these standards. Listed below are the most frequently asked questions and answers on this topic.
Q What can a nurse say to a patient’s family members who call the nursing unit to inquire about the patient?
A Unless the patient has indicated Restricted Access in BICS, it is permissible to give family members the standard one-word condition indicator. It is also permissible to inform the family member to kindly call the patient directly, unless s/he is unable to use the phone in his or her room.
Q When looking up patient names in BICS, if “Y” appears next to Privacy Notice, does this mean that a nurse cannot provide family members with any information on the patient?
A No. The “Y” indicates that the patient has received the Privacy Notice. It does not indicate that patient has “restricted access” in the BWH Patient Directory.
Q Can you clarify what “Restricted Access” means?
A In BICS, if “Yes” appears in the field “Restrict Patient Name in BWH Public Directory,” this means that no information can be given to the public regarding the patient’s presence and/or treatment at BWH. The hospital will not accept any mail, flowers, or phone calls on the patient’s behalf. Therefore, the patient will need to make arrangement on their own to provide details of his/her location and/or condition via a designee. If inquiries are received, the response from hospital staff must be, “We have no knowledge of this patient.”
Q How should a staff nurse respond to a clinician who does not have computer access and asks a nurse to look up lab values of a family member, who is a patient?
A. The nurse should advise the clinician that he or she cannot accommodate the request without the family member’s permission. The nurse should suggest that the clinician either contact his or her family member’s physician, speak with that person directly, or bring written authorization from the family member to the Medical Records Department, which could provide the clinician with the information.
Q What information on a patient can be listed in the hospital directory and can this be shared with the public?
A The Privacy Rule permits hospitals to continue the practice of providing directory information to the public, unless the patient has specifically chosen to opt out. The Rule states that hospital may maintain a directory that includes:
Patient’s Name
Location in the facility
Condition in general terms
Religious affiliation
Q Under HIPAA, can nurses leave messages for patients at their homes, either on answering machines or with family members to remind them of appointments?
A Yes. The HIPAA Privacy Rule permits health care providers to communicate with patients at their homes, whether through the mail, by phone, or in some other manner. The Rule does not prohibit covered entities (BWH) from leaving messages for patients on answering machines. However, to reasonably safeguard the individual’s privacy, care should be taken to limit the amount of information disclosed on the machine. If you need to give specific instructions or results to the patient, such as medication dosage change or lab results, do not leave these details with a family member or on a machine, but request the patient to call back. Patients may also request no messages and/or an alternate communication method, which will need to be accommodated.
Q What other “Incidental Disclosures” are permitted under the HIPAA Privacy Rule, so long as reasonable safeguards are taken?
A Patients’ medical records may be maintained at the bedside or outside of exam rooms, so long as specific clinical data is protected (i.e. inside binder). Use of inpatient logs, such as whiteboards on nursing units are allowed as long as they do not contain any specific clinical information.
Q Who can I call if I have concerns or questions about HIPAA regulations?
A You may call:
Debbie Polansky, BWH HIPAA Project Manager, ext. 2-6676
BWH Patient Relations Department, ext. 2-6636
BWH Compliance Hotline, ext. 2-8907
Jackie Raymond, BWH Privacy Officer, etc. 2-6068
Q How can I access HIPAA information if I want to review a specific HIPAA policy or form?
A. Privacy/Confidentiality resources including HIPAA forms, policies and procedures can be found by accessing the BWH Intranet at
www.bwhpikenotes.org
.